The death of a child before his or her first birthday is a tragedy that occurs with surprising frequency in the United States. In 2013, there were more than 23,000 such deaths nationwide in a developed country with high expenditures on health care.
Infant mortality rates (the number of infant deaths per 1,000 births) globally and in the United States have been declining overall, but a disproportionately large number of infant deaths occurred among African Americans. Vital-statistic reports showed an overall infant mortality rate of 5.96 per 1,000 live births in the United States in 2013, worse than rates in 33 other countries, including Cuba.
The rate for non-Hispanic white people that year was 5.1, but the rate for African Americans was 11.1. This rate places African Americans in the company of less developed and poorer countries, including Romania (10.5) and the United Arab Emirates (11.3).
Infant mortality is generally associated with poverty, low maternal education, poor health-care access and lack of adequate prenatal care. However, studies have shown that affluence, high maternal education and health insurance do not necessarily protect African Americans from poor pregnancy outcomes or infant mortality. An Institute of Medicine report found that the risk of preterm birth in college-educated African American women was greater than that for white women with fewer than eight years of education.
Preterm birth — when infants are born before 37 weeks of gestation — is a major risk factor for infant mortality. Infants weighing less than 5.5 pounds at birth — considered low-birth-weight — and those under 3.3 pounds — very-low-birth-weight — also face increased risk of infant mortality. African Americans are more likely to have preterm and low- and very-low-birth-weight babies.
Montgomery County, which consistently ranks as one of the nation’s healthiest and wealthiest counties, has significant racial health inequities. In 2014, according to the annual Infant Mortality in Maryland report, the infant mortality rate in Montgomery County stood at 4.8 per 1,000 births. Among white county residents, the rate stood at 3.6, but it was 8.3 for African Americans in the county.
Montgomery County has responded with initiatives to decrease infant mortality and improve pregnancy outcomes. Its Fetal and Infant Mortality Review Board examines cases of loss to identify health-care delivery system successes and failures. The board regularly makes recommendations to its Community Action Team, a diverse group of public and private organizations charged with carrying out recommendations.
It is critical to increase awareness in health-care providers and the general population that all African American women have a higher risk of preterm and low-birth weight infants and an increased risk for infant mortality. Regular visits to a primary-care provider can promote optimal health before pregnancy and treat medical issues such as diabetes, obesity and hypertension.
Case management programs have reduced poor pregnancy outcomes. In Montgomery County, the African American Health Program’s Start More Infants Living Equally program, known as SMILE, has had successes, including in having more babies born at a healthy weight compared with the countywide figure. The program offers home visits by nurses and case managers to pregnant African American women and new mothers and their infants.
The Community Action Team is working to increase participation in the program by African American women, including college-educated, privately insured and professional women.
Because the causes of preterm birth in African American women are not completely understood, studies are needed to examine whether stress, anxiety, depression and racism contribute to infant mortality, as well as ways to mitigate these factors.
It is the hope of the Fetal and Infant Mortality Review Board and its Community Action Team that infant mortality and related racial and ethnic disparities will dramatically decline over the coming years, allowing more infants to live to their first birthdays and enjoy many more thereafter.
The writer, a clinical investigator and family physician, is a member of the African American Health Program Infant Mortality Collaborative, the Montgomery County Fetal and Infant Mortality Review Board and the Community Action Team.